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Everything has its limitations; Confidentiality in therapy is no exception. It is a common misperception that enrollment in therapy guarantees any and all disclosures are protected by law. Whether you’re unloading your guilt about murdering your neighbor, bragging about beating up your elderly in-law or planning a deadly overdose for the upcoming weekend, a therapist is required to sort through their client’s information and determine whether a legal responsibility to break confidentiality exists. The vast majority of disclosures from client to therapist are held in the strictest of confidence; obviously “trust” would be significantly impaired otherwise. However, clients often find themselves in a position of regret when the information they disclosed requires the breach of confidentiality by the provider. Clients should be aware of the limits to confidentiality before and during treatment, thus putting them in the position of control regarding the degree of disclosure they wish to make to their therapist. When a client appears to be moving in a direction of reportable disclosure, a good therapist will interrupt and remind the client of the law. This allows the client to move from a vulnerable “emotional” mind to a “wise and rational” mind, allowing them to re-assess whether the information about to be shared best be kept to themselves. So what constitutes the right and responsibility of a provider to breach their client’s confidence? First and foremost, disclosure regarding serious and imminent danger to either themselves or others, due to a mental illness, automatically removes the client from a protected status. Therapists are required to intervene when a client references being suicidal, demonstrates a lethal plan, shows access to the means and expresses intentions to die. As providers, we are frequently asked the question “How can you betray your client like that? If they can’t tell you without being shipped to the nut house, who can they tell?” Our response is always the same: We are required by law to intervene in such cases. Failing to do so could potentially lead to not only the client’s death, but the provider’s right to practice psychotherapy for the long-haul. It is not a difficult decision to make; after all, most suicidal intentions pass after a brief duration of time. Providing that duration of time is the therapist’s responsibility. Intentions to seriously injure or kill somebody else due to a mental illness, also requires the therapist to break confidentiality. Not only must the therapist intervene directly with the client, but the intended victim must also be notified of the threat. If an individual has intentions to injure or kill somebody else, but does not suffer from a mental illness, then the responding party becomes law enforcement. In the event that a client is determined to be gravely disabled due to a mental illness, the therapist can break confidence to ensure the safety of the client. An example of this would include a person suffering from schizophrenia who is found wandering the streets naked in the middle of winter. Obviously this individual is not of the capacity to ensure his safety, thus it becomes the mental health provider’s responsibility to assume the position of protector of this vulnerable individual. It must be clearly stated that there is nothing illegal about being “crazy” or mentally ill. Just because a person is delusional doesn’t justify a breach of confidentiality. It is only when the “crazy” puts them at immediate and serious risk of harm that protective action can be taken. Just because a mentally ill female calls into dispatch with reports that little green monsters are recycling aluminum cans from her dumpster doesn’t mean she is at risk of immediate and serious harm. Thus a therapist would not be able to disclose that person’s enrollment in treatment to doctors, law enforcement, family, etc. Often therapists are subpoenaed by attorneys to testify in court. If the client refuses to sign a release of information to the court allowing the therapist to testify on his behalf, the therapist is prevented, by law, from disclosing confidential client information. It is only by the order of the court that mental health therapists can be required to breach confidentiality. Even then, therapists are required to minimize the degree of disclosure to minimal information necessary to answer the question. This of course, can be tricky. Therapists are mandated reporters. Thus if a therapist becomes aware of child or elderly abuse, a report to the Department of Health and Human Services is required within 24 hours. So whether you dislike your in-laws or not, disclosing your secret of joyfully torturing them with cattle prods to your therapist does not mean your “secret is safe with us.” Clients should definitely be aware there is no statute of limitation on sexual abuse. If a middle aged woman reports during therapy she was molested by her neighbor John Doe at the age of 12, a report to Human Services is still required. Whether the report is shredded, buried, burned or investigated is at the discretion of the Social Service agency. All other disclosures require the written consent of the client. This includes their family, doctors, probation officers, teachers, etc. Mental health does not fit the provider-to-provider definition for openly exchanging medical information without client consent. This can be very frustrating to the doctors who refer their patients for services, understandably. In review of these limitations to confidentiality, anyone considering enrollment in psychotherapy might best consider the motto “silence is golden” if not prepared for certain information to be passed on to mandated agencies.